Mass shootings often put a spotlight on mental illness, but figuring out which conditions should keep someone from having a gun is no easy task

Every time the country is shaken by a tragic mass shooting and the loss of innocent lives, mental illness and its role in the actions of the mass shooter come under scrutiny.

Mental illness again became a central theme after the mass shooting in Maine on Oct. 25, 2023, in which records suggest that the shooter had a history of serious mental health issues^[1]. Months before the tragedy, the family of gunman Robert Card, as well as Army Reserve staffers, had contacted law enforcement expressing high levels of concern about his mental health and noting his access to guns.

Since 1999, 19 states along with the District of Columbia have passed legislation^[2], commonly known as red flag laws^[3], that allow law enforcement and other people in a person’s life to petition for removal of firearms when there are imminent safety concerns about a gun owner. However, reports suggest that this law is rarely used^[4].

Maine, though, has what’s known as a yellow flag law^[5]. It requires reporting to local law enforcement that a person poses an imminent threat, but it then relies on the police to take the person into custody, order a mental health evaluation and request a court order to have that person’s guns removed. The yellow flag law was not used^[6] in Card’s case.

The relationship between mental illness and guns, and risk mitigation, is complicated. Specifically, there is no clear and uniform consensus on who should determine when to restrict access to firearms – should it be a psychiatrist, an independent forensic psychiatrist, a committee of psychiatrists or a judge? The majority of people with mental illness do not seek treatment^[7].

In that light, it might make sense to mandate a psychiatric examination into the background check process for purchasing a gun. As severe mental illness can start at any point in life, will gun owners need periodic psychiatric assessment, akin to a vision exam for renewing a driver’s license? If so, who will pay for the visits?

I am a trauma psychiatrist^[8] who regularly deals with the outcome of gun violence, whether in victims or first responders. In my book “Afraid^[9]: Understanding the Purpose of Fear and Harnessing the Power of Anxiety,” I have examined mental health issues related to gun violence and the social consequences of mass shootings.

The complexity of defining mental illness

The term “mental illness”^[10] covers a wide range of conditions, and there are more than 200 diagnoses listed in the most recent version of the Diagnostic Statistical Manual of Mental Disorders^[11], which is the gold standard for psychiatric diagnosis in the U.S. Mental illness includes diverse conditions like phobias, social anxiety disorder^[12], post-traumatic stress disorder^[13], hair-picking disorder^[14], gambling disorder^[15], schizophrenia^[16], dementia^[17], various forms of depression^[18] and personality disorders, such as antisocial personality disorder.

Mental illnesses are also very common: Nearly 1 in 5 people experience clinical depression^[19] during their lives; 1 in 5 people experience an anxiety disorder; 1 in 100 experience schizophrenia^[20]; and nearly 8 in 100^[21] of the general population experiences PTSD. People with higher exposure to trauma, such as veterans^[22] and first responders^[23], have higher rates of PTSD, up to about 30%.

So when suggesting that gun access should be restricted for people with mental illness, does that mean all of these conditions? Or just some, or some in defined circumstances? For example, should all veterans with PTSD or those with social anxiety disorder have their guns removed? Neither of these conditions is known to commonly impair judgment.

Defining the specific conditions that can impair judgment or significantly increase risk of harm to self or others is an important step in this process, which needs serious involvement of mental health professionals, stakeholders, law enforcement and policymakers.

Knowing when a person could be a risk of harm

The majority of mental illnesses do not pose a risk^[24] to others. When there is a risk, in the majority of cases when someone is involuntarily admitted to a psychiatric inpatient unit, it is not because the person poses a risk to others. Rather, it is more often the case that the person is at risk of self-harm^[25], as in the case of a depressed, suicidal patient. Sadly, people with severe mental illness are often the victims of violence and abuse^[26].

In psychiatric disorders, concerns typically arise in acutely psychotic patients with paranoid delusions that convince them to harm others. This may happen in – but is not limited to – schizophrenia, dementia, severe psychotic depression^[27] or psychotic bipolar illness^[28].

These conditions are rather strongly associated with increased risk of suicide^[29], not homicide. Therefore, more realistic gun laws in regards to mental illness could also save many lives from suicide.

Substance use is a major contributor to violence^[30] in mental illness, and it needs to be included in the calculations when it comes to gun restriction. Other situations with increased risk of harm to others are personality disorders with a high level of impulsivity or lack of remorse, such as antisocial personality disorder^[31].

But the reality is that most people with personality disorders do not seek treatment and are not known to mental health providers.

It is also worth noting that most countries have a similar prevalence of severe mental illness compared with the U.S., yet they have much lower rates of mass murder^[32] than the U.S.

The harms of using ‘mental illness’ so vaguely

Every time mental illness is linked by the media or politicians to acts of violence^[33], the highly charged emotions of the moment can affect those with mental illness and their families, and that can perpetuate stigma.

When “mental illness” is vaguely addressed in gun debates^[34], those with a psychiatric condition such as anxiety or phobia but without an increased risk of violence or impairment in judgment may avoid seeking treatment.

Mental illness gun laws that can have real preventive impact

In my view, to turn the focus on the role of mental illness in gun violence into meaningful actions, the following steps are needed:

– Clear, uniform criteria need to be established on when mental illness justifies restriction of access to firearms. Would this be specific mental disorders or specific mental disorders in crises? This requires defining signs of imminent threat to self or others, and also defining how and when a person is relieved of that status. A great deal of discussion and coordination will be needed between mental health, legal and law enforcement experts.

– As it was noted before, the majority of patients with mental illness do not seek care. A comprehensive preventive plan would necessitate screening everybody who applies to purchase a firearm. This step ensures meaningful screening, as well as avoiding discrimination. Other countries such as Japan, Canada, New Zealand and Austria have such requirements^[35].

– Since potentially dangerous psychiatric conditions can begin at any age in an otherwise healthy person, regular mental health screening for gun owners would be justified, similar to eye exams for drivers.

– There should be clear mechanisms for determining lack of mental fitness for access to firearms when concerns are raised by those who know the person or by law enforcement. Red flag gun laws are a good beginning for this path.

The bottom line is that determining who may or may not have access to firearms based on mental illness, as outlined, is indeed very challenging and requires more serious work. And the common denominator in all these tragedies still is the access to assault rifles.

This is an updated version of an article^[36] that was originally published on Feb. 26, 2018.

References

1. ^{^} history of serious mental health issues (www.cbsnews.com)
2. ^{^} passed legislation (www.poynter.org)
3. ^{^} red flag laws (www.pbs.org)
4. ^{^} reports suggest that this law is rarely used (www.poynter.org)
5. ^{^} yellow flag law (www.cbsnews.com)
6. ^{^} was not used (www.cnn.com)
7. ^{^} do not seek treatment (www.nimh.nih.gov)
8. ^{^} trauma psychiatrist (www.starclab.org)
9. ^{^} Afraid (rowman.com)
10. ^{^} “mental illness” (www.nimh.nih.gov)
11. ^{^} Diagnostic Statistical Manual of Mental Disorders (www.psychiatry.org)
12. ^{^} social anxiety disorder (www.mayoclinic.org)
13. ^{^} post-traumatic stress disorder (adaa.org)
14. ^{^} hair-picking disorder (www.nhs.uk)
15. ^{^} gambling disorder (www.psychiatry.org)
16. ^{^} schizophrenia (www.psychiatry.org)
17. ^{^} dementia (www.cdc.gov)
18. ^{^} depression (www.psychiatry.org)
19. ^{^} 1 in 5 people experience clinical depression (www.nami.org)
20. ^{^} 1 in 100 experience schizophrenia (www.nimh.nih.gov)
21. ^{^} nearly 8 in 100 (www.ptsdunited.org)
22. ^{^} such as veterans (www.ptsd.va.gov)
23. ^{^} first responders (theconversation.com)
24. ^{^} do not pose a risk (www.ncbi.nlm.nih.gov)
25. ^{^} risk of self-harm (www.ncbi.nlm.nih.gov)
26. ^{^} often the victims of violence and abuse (doi.org)
27. ^{^} psychotic depression (www.webmd.com)
28. ^{^} psychotic bipolar illness (www.healthline.com)
29. ^{^} increased risk of suicide (psychiatryonline.org)
30. ^{^} major contributor to violence (doi.org)
31. ^{^} antisocial personality disorder (www.mayoclinic.org)
32. ^{^} much lower rates of mass murder (www.who.int)
33. ^{^} mental illness is linked by the media or politicians to acts of violence (blogs.bmj.com)
34. ^{^} vaguely addressed in gun debates (www.nytimes.com)
35. ^{^} have such requirements (www.nytimes.com)
36. ^{^} an article (theconversation.com)